Avoiding Complications

Nurturing Your “Health Bank”

Most people who are diagnosed with diabetes or prediabetes are told at some point about the long-term damage diabetes can do, such as causing heart attack and stroke, blindness, kidney disease, and limb amputations. Unfortunately, too few are also told that all of these complications are largely preventable — through a combination of healthy lifestyle practices, frequent checkups and laboratory tests for screening and monitoring, and medication when necessary.

This may sound like a long list of things to do, but it may be simpler than you think — if you focus your efforts on the areas that will have the most impact for you.

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Understanding and monitoring the big picture of your overall health with diabetes can be achieved by keeping tabs on five simple medical tests: HbA1c, blood pressure, blood lipids (cholesterol and triglycerides), microalbumin, and a dilated eye exam.

These tests are currently the best measures available to indicate each person’s individual health risks with regard to diabetes. Yet despite these tests being widely accessible and easy to administer, fewer than 42% of adults with diabetes have either had them or understand what the results mean, according to an April 2006 report by USA Today.

Why aren’t more people with diabetes aware of these critical tests or their own personal results? There are lots of possible reasons, ranging from not being informed, to not understanding the information or its importance, to feeling too overwhelmed by other concerns to act on the information.

“So often people with diabetes focus on the stuff they feel guilty about (usually weight or food), when that may not even be their most critical health issue. What they don’t usually do is get the hard facts on where they stand in terms of their own diabetes health risks. But this is what’s really going to improve the quality and length of their life,” says Dr. Richard Jackson, Director of Medical Affairs, Healthcare Services, at the Joslin Diabetes Center in Boston.

Dr. Jackson’s long-standing notion is that everyone with diabetes should track their lab test results just as carefully as they track their money in the bank. In our book Know Your Numbers, Outlive Your Diabetes, Dr. Jackson and I describe how to create a simple “balance sheet” that can help people see clearly where they have the most “health dollars” in the bank and where their most urgent “health debts” lie. (For a sample sheet, click here.) By taking action where it’s most needed, readers can achieve the long, healthy, complication-free lives they want.

Collect your numbers

The first step in creating your health balance sheet is to gather your test results. Most people have had at least some of these tests conducted at some point, but they may not know exactly how long ago, what the tests measured, or what the results were. For clarity, here’s what each one does:

HbA1c. The HbA1c test (also called the glycosylated hemoglobin test or the A1C test) is a measure of the amount of glucose in your blood over the previous 2–3 months. This test complements daily blood glucose monitoring by providing a broader picture than the “snapshots” provided by your meter. Keeping your HbA1c test results in the recommended range lowers your risk of all diabetes-related complications.

Blood pressure. This test, which is usually done by placing an inflatable cuff around your upper arm, determines the force of blood flow through your blood vessels. High blood pressure raises the risk of stroke, heart problems, and kidney disease.

Lipid profile. This is a group of blood tests that measure (or enable the lab to calculate) your total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides (another type of blood fat). Results are used to help determine your risk of heart attack or stroke.

Microalbumin. This urine test searches for small amounts of a protein called albumin, which leaks into the urine when the kidneys are becoming damaged. This is the test most frequently neglected in people with diabetes, yet it is by far the most sensitive test for identifying risk of future kidney problems.

Eye exam. A yearly dilated eye exam (in which the pupils are enlarged using eye drops) allows the eye doctor to see the backs of the insides of your eyes to check for diabetes-related eye problems (as well as non-diabetes-related eye problems).

If you don’t already have copies of your most recent test results, you will need to call your doctor’s office and ask for them. Remember that you have the right to obtain copies of your medical records, so don’t take no for an answer if you encounter resistance. In addition, don’t accept the answer that your test results are “OK” or “fine.” At least for HbA1c, blood pressure, cholesterol and triglyceride levels, and microalbumin, you want a numerical answer — just as you would if you went to the bank and asked for an update on your account balance.
Your eye exam results, which you may need to get from your eye doctor rather than your primary diabetes care doctor, are less straightforward, because there are no numerical results for diabetes-related eye problems, and it’s unusual for eye doctors to provide patients with written records. However, your eye doctor is required to provide you with a report if you request one, and there are some standard terms that eye doctors use to describe the most common diabetes-related eye problem, retinopathy. The doctor should be able to explain the significance of your results to you.

As you collect your results, note when the tests were last done. Anything over a year old is too old, and you should schedule new tests immediately. According to the Joslin Diabetes Center, the frequency of these tests should be as follows:

HbA1c test: every three to six months

Blood pressure: at least once a year, but you can take advantage of every doctor’s appointment to have your blood pressure checked

Microalbumin, lipids, and eye exam: all annually, unless you have concerns that might require more frequent checks

Once you have your test results in hand, you can start thinking about how to respond to them.

Setting priorities

Knowing where to focus your efforts may be the hardest part of managing diabetes. Many people feel overwhelmed, believing they have to do everything at once. But doing everything at once is just too difficult, and it may not even make sense from a health standpoint since you may expend a lot of effort toward achieving a goal that has little impact on your health. You need to know what your real health risks are so that you can pinpoint your efforts to make the biggest impact on improving or maintaining your health.

Once your five tests are current and you’ve obtained the results, compare your results to the ideal target ranges to see where you stand and where you need to take action. The results that are furthest from the ideal target ranges are your “debts.” These are the numbers that require action first.

Keep in mind that while the target ranges shown here have been associated with a lowered risk of complications for the general population with diabetes, your personal goals should be individualized with the help of your health-care providers.

HbA1c. According to the American Association of Clinical Endocrinologists, if your test result is at or under 6.5%, you’re right on target, so there’s no need for you to take immediate action to lower it. In other words, you’ve got lots of HbA1c dollars in the bank. If your HbA1c is between 6.5% and 7.0%, you still have a pretty good balance in your health account. But if your HbA1c is in the 8.0% to 9.0% range, this is an area of concern that should be addressed as soon as you’ve taken care of any matters that are even more pressing. If your HbA1c is 9.0% or over, this signifies a serious health risk that you’ll want to address immediately.

Blood pressure. Blood pressure is reported as two numbers, such as 120/80 mm Hg. The top number is called the systolic pressure, and the bottom number the diastolic pressure. Both are vital in assessing your risk of heart disease. For example, for every 10 points you reduce your systolic pressure (the top number in your blood pressure result), you reduce your chance of heart attack and stroke by 15% to 20%. And while the current recommendation for people with diabetes is to maintain a blood pressure lower than 140/80 mm Hg, studies show that there is additional benefit to lowering the systolic blood pressure to 120 mm Hg or lower. Anything over 140 mm Hg systolic is considered high blood pressure.

According to Dr. Jackson, high blood pressure is an underappreciated diabetes risk factor. Most people realize that it’s somehow important to their health, but often neither they nor their health-care providers recognize its fundamental role in predicting cardiovascular risk for people with diabetes.

Blood lipids. The current recommendations of the National Cholesterol Education Program are to aim for an LDL cholesterol level below 100 mg/dl for people at high risk of heart disease. For people who already have heart disease or who are at very high risk, the goal is an LDL cholesterol below 70 mg/dl. However, a growing body of research suggests that lower levels may be better for more people. For this reason, Know Your Numbers, Outlive Your Diabetes sets a target of 80 mg/dl for people with Type 2 diabetes, as well as a goal of an HDL cholesterol level of more than 45 mg/dl (in the case of HDL, higher is better), and triglycerides below 150 mg/dl.

Microalbumin. A number of tests can be used to measure albumin in urine, but the preferred test measures the albumin-to-creatinine ratio. This test is preferred not least because it requires a small urine sample; in contrast, another test for microalbumin requires collecting all urine excreted over 24 hours.

A normal albumin-to-creatinine ratio is less than 30 milligrams of albumin per gram of creatinine (mg/g). A diagnosis of microalbuminuria is given when the test result is between 30 mg/g and 300 mg/g, and a diagnosis of macroalbuminuria requires a level over 300 mg/g.

Because albumin excretion is variable and may be affected by factors such as strenuous physical activity, a urinary tract or other infection, high blood glucose, or high blood pressure on the day of the urine test, the test result should be confirmed in two or preferably three separate tests done over a 3- to 6-month period before a diagnosis is made.

Eye exam. Terms that doctors commonly use to describe the presence or absence of retinopathy include the following:

No evidence of diabetic retinopathy

Mild, minimal, or moderate background retinopathy

Nonproliferative retinopathy

Preproliferative retinopathy

Proliferative retinopathy

Obviously, the desired result of an eye exam is “no evidence of retinopathy” or any other eye disease. If you have proliferative retinopathy, laser therapy can be effective at slowing or stopping the progression of retinopathy. At the stages in between, no immediate treatment may be necessary, but you will want to know if you have progressed from one stage to the next so that you can reevaluate your overall diabetes regimen to determine whether your blood glucose and blood pressure control are at the levels recommended for preventing diabetes complications.

People are often surprised by their test results. Those who’ve spent months fretting about their HbA1c might find it at a respectable level (around 7.5%), while their blood pressure is dangerously high (over 140 mm Hg systolic, for example). What the “diabetes health account” approach does is allow you to pinpoint any results that are out of range, so you can focus on the one or two issues currently most critical for you personally. It’s essentially a do-it-yourself approach to good health. That means it’s your job (not your doctor’s) to collect those health dollars — by knowing your test results and taking the most effective actions to improve them where needed.

Active improvement

So what do you do about your health risks once you identify them? That’s an excellent question, and the answer depends on where your problem areas are and how far you are from your goal range. If you are very far from goal range, immediate and aggressive action — most likely requiring the involvement of your physician — is needed.

If you are close but not quite in goal range, there are a number of very effective strategies that you can “cycle through” to bring your test scores into target range. The idea in this case is to start with the least invasive approach, such as lifestyle changes like diet and exercise, then progress to more aggressive treatments such as medication as necessary. If the first recommendation doesn’t yield results, you can move on to the second, and so on.

The idea here is not to bypass professional medical care but rather to work together with your doctor, diabetes educator, dietitian, or other health professional at a new proactive level, taking initiative and full “ownership” of your diabetes care. Dr. Jackson advises people to think of their diabetes as a small business and their health-care team as their consultants. The objective is to go into appointments armed with information on where the “business” stands, and be prepared with clear goals and/or questions you want your consultants to advise you on. This way, rather than just passively answering questions, you can get a whole lot more meaningful input from your interactions with your health-care team.

In the case of high blood pressure, you might start by investing in a home blood pressure monitor, then talk to your doctor about taking blood-pressure-lowering drugs such as ACE inhibitors, angiotensin II receptor blockers (ARBs), or beta-blockers. Aerobic exercise can be very beneficial when done regularly, and there are many specific — but not drastic — changes you can make in your diet to help bring blood pressure levels down.

Lowering your microalbumin test result is almost always a matter of lowering your blood pressure. ACE inhibitors and ARBs also have a directly protective effect on your kidneys, separate from their effect on lowering your blood pressure. When taken together, the two types of drugs are even more helpful. So a drug from one of these two classes is almost always the first choice in treating high blood pressure — and at the same time lowering microalbumin — in people with diabetes. You can also improve your kidney health by lowering your blood pressure target and working to reduce your HbA1c if it is high.

The point is that you’re much more likely to significantly improve your health if you pinpoint your focus, then take a step-by-step approach to addressing your most critical risks.

Confidence is key

In October 2006, Forbes reported that “diabetes is dragging down America’s health (statistics).” According to new data from the US Centers for Disease Control and Prevention, a good half of the estimated 21 million adult Americans with diabetes at that time rated themselves as having only “fair” or “poor” health — levels that are associated with diabetes-related complications.

Not only is this frightening, but it is frustrating, since this does not need to be the case. Part of the trouble, of course, is that many people don’t have access to sufficient medical care, but the other factor is simply inertia: Too many people ignore their diabetes because they feel overwhelmed or hopeless, believing that their efforts to control their diabetes will have no real effect.

Motivation comes from believing that your actions (not just your doctor’s) matter. The “diabetes health account” approach outlined in Know Your Numbers, Outlive Your Diabetes offers a simple way to chart your own progress and see that your efforts have made a difference. This step-by-step set of strategies illustrates that if your blood pressure is high, for example, it can always be lowered into a safer range just by employing the right combination of lifestyle changes and medicines that are effective for you.

To reiterate, the most important first step to living longer with diabetes and preventing its long-term complications is finding out where you stand with this condition. Taking control also means finding a way to manage your diabetes every day without going crazy and without letting it rule your life.

The concept of “knowing your numbers” is really quite simple. As HealthiNation video producers (www.healthination.com) note, “Most people can rattle off their important numbers with ease. They know their date of birth, Social Security number, and even their credit scores. But if you ask people if they know their cholesterol, blood pressure, and blood glucose levels — they have no clue. Knowing the RIGHT numbers can make the difference between life and death.”

The human mind has an enormous capacity for retaining information, but there’s really no need to memorize your diabetes health numbers. What’s important is simply to get the tests and log the results regularly. And of course, you need to feel empowered to take action on anything that’s out of range.

An ounce of prevention

One thing you can be sure of: If everyone tracked and acted on these values regularly, their outlook for a long and healthy life would be a lot rosier. Keep in mind that diabetes does its damage slowly, over
the long term, so feeling fine today does not mean that you are fine. Only your test results can tell you where you stand, and only by keeping tabs on them can you ensure good health going forward.

Try thinking of keeping your test results in target range as your own personal seatbelt law. It’s something everyone is required to do for their own protection. Some people will be lucky enough to avoid accidents, so the fact that they were foolish enough not to wear a seatbelt may not harm them. But that’s largely up to chance. No one can predict whose luck might turn for the worse. By keeping your HbA1c and other health factors in range you can ensure a healthier future. Even if you discover complications starting to set in, the damage is much more likely to be treatable or even
reversible if it’s caught early.

Of course, the thought of caring for your diabetes for the rest of your life can seem daunting. But thinking about it in terms of your diabetes health account may help remove some of the dread. It’s just another practical area — like your financial security — that you want to manage as well as you possibly can to ensure a brighter future.

Amy Tenderich is the author of the blog Diabetes Mine, which can be read at www.diabetesmine.com, and coauthor, along with Richard Jackson, MD, of Know Your Numbers, Outlive Your Diabetes, published in 2007 by Marlowe & Company. Dr. Jackson is Director of Medical Affairs, Healthcare Services, at the Joslin Diabetes Center in Boston and an Assistant Professor of Medicine at Harvard Medical School.

Disclaimer Statements: Statements and opinions expressed on this Web site are those of the authors and not necessarily those of the publishers or advertisers. The information provided on this Web site should not be construed as medical instruction. Consult appropriate health-care professionals before taking action based on this information.